Acute Questionnaire

ACUTE CARE Form

For the ACUTE CARE program, you only need to fill out the following form and send it to homeopathyforwomen @ gmail.com by copy-pasting the whole text. Then I'll call you to meet on Zoom or to ask for more details.

Acute care is for 7 days. Price has to be paid in advance: 350₪ (= 100$ - 50$ before and 50$ at the time of the meeting) via this payment platform (Nedarim 100% safe). Price doesn't include the remedy. See below for examples of acute care issues. It has to be less than 30 days old, otherwise you need to get the Chronic Care program.

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Name of the client (first and last):

Date of birth:

Email:

Address:

Phone:

Best time to call you:

1. What is your main complain? Choose only one. You can choose from the list below or add your own:

Tooth pain,
colic,
earaches, otitis media,
asthma,
cough or croup,
coryza (common cold symptoms),
diarrhea,
constipation,
skin rash,
bronchitis,
backaches (lumbago, sciatica, strain),
dyspepsia,
hiccoughs,
hemorrhoids,
jaundice,
nausea, vomiting, morning sickness,
vertigo,
emotional issue, acute grief,
kidney infection,
sore throat, tonsilitis,
food poisonings
strep throat
pneumonia,
sinus issues,
mononucleosis,
OB/GYN issue,
OB/GYN pregnancy or birthing,
infectious disease,
insect bite, insect sting, tic bite,
canker sore, mouth ulcers,
allergies, hay fever

2. When did the complaint start and what happened then (think of any type of cause, either physical or emotional, example: trauma, travel, someone died, vaccine, etc.)

3. What makes the complaint better (heat, warmth, open air, cold drink, cold application, people around, quiet, dark room, etc.)?

4. What makes the complaint worse (noise, light, people around, food, smell of food, stuffy room, etc.)?

5. Which time of day is the complaint worse (in the morning, the evening, at 3AM?)

6. Give other symptoms that come with the main complaint (toothache with nausea, headache with vomiting, sinuses with anger, etc.)

7. Anything else you'd like to add that's important?

Were you referred to us?

How did you find out about us (Google, Newsletter, etc.)?

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ALL INFORMATION IS KEPT CONFIDENTIAL

By sending us this form via email (homeopathyforwomen @ gmail. com) you give us permission to contact you by phone, Zoom and/or email.
We will contact you as as soon as possible.

We reply to all inquires promptly for acute care.
If you do not hear back in 2 hours during our business hours, call us 08-858-9518. From outside of Israel: 972-8858-9518

Please send this form only once.

Comments

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